Minimally invasive resection of spinal hemangioblastoma: feasibility and clinical results in a series of 18 patients

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OBJECTIVE

Hemangioblastomas are benign, highly vascularized tumors that can occur sporadically or as part of von Hippel-Lindau (VHL) disease. Traditionally, spinal hemangioblastomas have been surgically treated via an open approach. In recent years, however, minimally invasive techniques using tubular retractors have been increasingly applied in spine surgery. Such procedures involve less tissue trauma but are also particularly demanding for the surgeon, especially in cases of highly vascular tumors such as hemangioblastomas. The object of this study was to evaluate the safety and efficacy of minimally invasive resection of selected spinal hemangioblastomas.

METHODS

The authors conducted a retrospective single-center study of all patients who, between January 2010 and January 2018, had been operated on for spinal hemangioblastoma via a minimally invasive approach performed at the surgeon’s discretion. The surgical technique is described and the pre- and postoperative neurological and imaging results were analyzed descriptively. The primary outcome was the postoperative compared to preoperative neurological condition (McCormick grade). The secondary outcomes were the extent of tumor resection and postoperative complications.

RESULTS

Eighteen patients, 12 female and 6 male, harboring a total of 19 spinal hemangioblastomas underwent surgery in the study period. Seventeen patients had stable neurological findings with stable or improved McCormick grades (94.5%) at a mean of 4.3 months after surgery. One (5.5%) of the 18 patients developed progressive neurological symptoms with a worsened McCormick grade that did not improve in the long-term follow-up. Sixteen of the 18 patients had VHL disease, whereas 2 patients had sporadic spinal hemangioblastomas. In all patients, postoperative MRI showed complete resection of the tumors. No other surgery-related perioperative or postoperative complications were recorded.

CONCLUSIONS

A minimally invasive approach for the resection of selected spinal hemangioblastomas is safe and allows complete tumor resection with good clinical results in experienced hands.

ABBREVIATIONS DREZ = dorsal root entry zone; VAS = visual analog scale; VHL = von Hippel-Lindau.

Article Information

Correspondence Jan-Helge Klingler: Freiburg University Medical Center, Freiburg, Germany. jan-helge.klingler@uniklinik-freiburg.de.

INCLUDE WHEN CITING Published online August 9, 2019; DOI: 10.3171/2019.5.SPINE1975.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Minimally invasive posterior approach to the spine using a nonexpandable tubular retractor system. A: Several dilators as well as an operating tube (diameter 20 mm, length 6 cm) in situ. Views through the tube using an operating microscope with magnification follow. B: After incision of the dura and subtotal removal of the hemangioblastoma, a small, coagulated residual tumor (arrow) as well as the emptied tumor-associated cyst (asterisk) is visible. C: Dura closure with 5-0 Prolene sutures using a bayonet microneedle holder. D: After closure of the dura, the tube is slowly removed and small muscular vessels are coagulated. Note that the muscle fibers return to their original position and leave hardly any dead space. E: A small wound after closure (2.5 cm). Figure is available in color online only.

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    Minimally invasive approach using an expandable tubular retractor system. A: The patient is prone on the operating table. The operating level has been marked under fluoroscopic control. B: Access to the posterior spine through the paravertebral muscles is achieved using dilators. C: Inserted expandable tubular retractor system in retracted position. D and E: Inserted expandable tubular retractor system in expanded position. F: Wound after closure (4 cm). Figure is available in color online only.

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    Case 3. A: Preoperative MRI scans showing a small intramedullary solid tumor portion of the hemangioblastoma at C6 (circle) with a large tumor-associated cyst extending from C2 to T5/6. B: Postoperative MRI scans obtained 4 months after minimally invasive resection of the small solid tumor portion at C6, showing total tumor resection and a considerably collapsed intramedullary cyst. Sequences from left to right: sagittal T2-weighted MRI, sagittal T1-weighted gadolinium-enhanced MRI, and axial T1-weighted gadolinium-enhanced MRI at C6.

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    Case 1. A: Sagittal T1-weighted gadolinium-enhanced MRI scan showing an intramedullary dorsal hemangioblastoma at C6 with perifocal edema. B: Axial slice showing the dorsally located hemangioblastoma. C: Postoperative MRI after total tumor removal and reduced edema. Case 6. D: Sagittal T1-weighted gadolinium-enhanced MRI showing an extramedullary intraforaminal hemangioblastoma at the thoracic level. E: Axial slice showing the lateral hemangioblastoma growing beyond the neuroforamen. F: Postoperative MRI after total tumor removal.

References

  • 1

    Ammerman JMLonser RRDambrosia JButman JAOldfield EH: Long-term natural history of hemangioblastomas in patients with von Hippel-Lindau disease: implications for treatment. J Neurosurg 105:2482552006

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2

    Boström AHans FJReinacher PCKrings TBürgel UGilsbach JM: Intramedullary hemangioblastomas: timing of surgery, microsurgical technique and follow-up in 23 patients. Eur Spine J 17:8828862008

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3

    Cornelius JFSaint-Maurice JPBresson DGeorge BHoudart E: Hemorrhage after particle embolization of hemangioblastomas: comparison of outcomes in spinal and cerebellar lesions. J Neurosurg 106:9949982007

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4

    Das JMKesavapisharady KSadasivam SNair SN: Microsurgical treatment of sporadic and von Hippel-Lindau disease associated spinal hemangioblastomas: a single-institution experience. Asian Spine J 11:5485552017

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5

    Deng XWang KWu LYang CYang TZhao L: Intraspinal hemangioblastomas: analysis of 92 cases in a single institution: clinical article. J Neurosurg Spine 21:2602692014

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 6

    Formo MHalvorsen CMDahlberg DBrommeland TFredø HHald J: Minimally invasive microsurgical resection of primary, intradural spinal tumors is feasible and safe: a consecutive series of 83 patients. Neurosurgery 82:3653712018

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 7

    Gandhi RHGerman JW: Minimally invasive approach for the treatment of intradural spinal pathology. Neurosurg Focus 35(2):E52013

  • 8

    Gläsker SKlingler JHMüller KWürtenberger CHader CZentner J: Essentials and pitfalls in the treatment of CNS hemangioblastomas and von Hippel-Lindau disease. Cent Eur Neurosurg 71:80872010

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9

    Gläsker SShah MJHippchen BNeumann HPHvan Velthoven V: Doppler-sonographically guided resection of central nervous system hemangioblastomas. Neurosurgery 68 (2 Suppl Operative):2672752011

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10

    Klingler JHVolz FKrüger MTKogias ERölz RScholz C: Accidental durotomy in minimally invasive transforaminal lumbar interbody fusion: frequency, risk factors, and management. ScientificWorldJournal 2015:5326282015

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 11

    Krüger MTKlingler JHJilg CSteiert CZschiedrich SVan Velthoven V: Polyglobulia in patients with hemangioblastomas is related to tumor size but not to serum erythropoietin. Hered Cancer Clin Pract 16:152018

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 12

    Lonser RROldfield EH: Microsurgical resection of spinal cord hemangioblastomas. Neurosurgery 57 (4 Suppl):3723762005

  • 13

    Lonser RRWeil RJWanebo JEDeVroom HLOldfield EH: Surgical management of spinal cord hemangioblastomas in patients with von Hippel-Lindau disease. J Neurosurg 98:1061162003

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 14

    Maher ERYates JRHarries RBenjamin CHarris RMoore AT: Clinical features and natural history of von Hippel-Lindau disease. Q J Med 77:115111631990

  • 15

    Malis LI: Atraumatic bloodless removal of intramedullary hemangioblastomas of the spinal cord. J Neurosurg 97 (1 Suppl):162002

  • 16

    Mandigo CEOgden ATAngevine PDMcCormick PC: Operative management of spinal hemangioblastoma. Neurosurgery 65:116611772009

  • 17

    Mobbs RJLi JSivabalan PRaley DRao PJ: Outcomes after decompressive laminectomy for lumbar spinal stenosis: comparison between minimally invasive unilateral laminectomy for bilateral decompression and open laminectomy: clinical article. J Neurosurg Spine 21:1791862014

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 18

    Neumann HPHBender BU: Genotype-phenotype correlations in von Hippel-Lindau disease. J Intern Med 243:5415451998

  • 19

    Papagelopoulos PJPeterson HAEbersold MJEmmanuel PRChoudhury SNQuast LM: Spinal column deformity and instability after lumbar or thoracolumbar laminectomy for intraspinal tumors in children and young adults. Spine (Phila Pa 1976) 22:4424511997

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 20

    Phan KMobbs RJ: Minimally invasive versus open laminectomy for lumbar stenosis: a systematic review and meta-analysis. Spine (Phila Pa 1976) 41:E91E1002016

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 21

    Rahman MSummers LERichter BMimran RIJacob RP: Comparison of techniques for decompressive lumbar laminectomy: the minimally invasive versus the “classic” open approach. Minim Invasive Neurosurg 51:1001052008

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 22

    Saliou GGiammattei LOzanne AMesserer M: Role of preoperative embolization of intramedullary hemangioblastoma. Neurochirurgie 63:3723752017

  • 23

    Takami TNaito KYamagata TKawahara SOhata K: Surgical outcomes of posterolateral sulcus approach for spinal intramedullary tumors: tumor resection and functional preservation. World Neurosurg 108:15232017

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 24

    Tredway TL: Minimally invasive approaches for the treatment of intramedullary spinal tumors. Neurosurg Clin N Am 25:3273362014

  • 25

    Turel MKD’Souza WPRajshekhar V: Hemilaminectomy approach for intradural extramedullary spinal tumors: an analysis of 164 patients. Neurosurg Focus 39(2):E92015

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 26

    Van Velthoven VReinacher PCKlisch JNeumann HPHGläsker S: Treatment of intramedullary hemangioblastomas, with special attention to von Hippel-Lindau disease. Neurosurgery 53:130613142003

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 27

    Wanebo JELonser RRGlenn GMOldfield EH: The natural history of hemangioblastomas of the central nervous system in patients with von Hippel-Lindau disease. J Neurosurg 98:82942003

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 28

    Yang YMWang DMJiang HZSha CYuan QGLiu JC: [Treatment of spinal cord hemangioblastoma by microoperations combined with embolization.] Zhonghua Yi Xue Za Zhi 88:130913122008 (Chinese)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 29

    Yaşargil MGTranmer BIAdamson TERoth P: Unilateral partial hemi-laminectomy for the removal of extra- and intramedullary tumours and AVMs. Adv Tech Stand Neurosurg 18:1131321991

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 30

    Zhu YJYing GYChen AQWang LLYu DFZhu LL: Minimally invasive removal of lumbar intradural extramedullary lesions using the interlaminar approach. Neurosurg Focus 39(2):E102015

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation

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